Thursday, April 23, 2009

Medical care for unvaccinated children

Some anonymous person asked me on Dr Bob's board whether I did not think that unvaccinated children should see a doctor when they are sick (well, anon phrased a bit differently, but I guess this is what s/he meant).

Of course they should. Every child has the right to adequate medical care. However, every parent who has a sick child has to think for a moment, before they haul it to the pediatrician:

Could my child be contagious? Could this be something dangerous to the other kids in the practise?

Parents of unvaccinated children have more dangerous diseases to consider than parents of vaccinated children - some parents do not think first. In the year 2000, an unvaccinated preteen came down with a fever and parents took him to a pediatrician's practise. He infected six children in the waiting room with measles, three of these children were under 12 months old. Two are now dying.ETA: Two of them developed SSPE as a consequence of their infection on that day and have since died after years of battling SSPE, Micha passed in 2013 and Natalie in 2011.

This is Micha in April 2005, about a year after the onset of his SSPE. He was 5 months old when he contracted measles in that practise (ETA: this movie needs a RealPlayer plugin):

The average survival time after onset of SSPE is 4 years. Micha is still alive. He is not better. He needs to take strong medication to keep the seizures at bay.

This is Natalie - she was 11 months old when she contracted measles from the same unvaccinated preteen. She came down with SSPE in Summer 2007:

The movies are in German, the mothers talk about the healthy children they had, their dreams and aspirations, watch for a minute or two to understand why we think that:

If parents think they know enough about measles not to vaccinate their children, they should recognize the signs of the disease and have a doctor who does home visits for medical care.

Catherina

Edited on 4/2/11 to exchange the Micha and Natalie movies for copies that run.
Edited on Feb 23/15 to add information that both Micha and Natalie have since died.

47 comments:

Yes it is. The actual risk of developing SSPE after measles infection in infancy has been calculated to be as high as 1 in 2000 (we will blog on measles and SSPE soon). This means, once your baby has recovered from measles, you have to worry about SSPE for another decade. Germany has had about 190 SSPE cases in the last 20 years and what is very scary is that for every SSPE case, you have to assume 10 direct measles fatalities.

I very strongly feel that the overall risk is nothing that parents trying to make a vaccine decision for their children can reasonably assume, and most probably ignore the risk of transmission, like they were living in a bubble.

the short answer is 0. I am working on the long answer as a blog (SSPE and MIBE after measles and/MMR vaccine). In the MMRII package insert, Merck estimates a risk of about 1 case of SSPE in 1 million vaccinees, however, this is based on a CDC report from 1988, when scientists still had to rely on temporal associations (difficult enough in a condition that has an onset delayed by up to a decade or more). In the meantime (over 20 years have passed), we can genotype the measles virus from the brains of SSPE patients and vaccine virus has NOT EVER been found. Therefore, the working answer is 0 (longer answer to come hopefully early next week).

Well, while your example is sad, you are also very much forgetting something. What you are forgetting to mention is that vaccination is not 100%. And MOST parents think they are. So it's also quite conceivable that a sick vaccinated child could be brought to the doctor's office with a VPD and risk exposing other unvaccinated children, partially vaccinated or too young to be vaccinated.

I think you need to also put some energy into educating parents that vaccination is not 100% and that bottom line, ANY sick child is potentially a risk to other regardless of vaccination status.

strangely enough, it was NOT a vaccinated child who brought measles into the doctor's office. If you look at outbreak reports, it hardly ever is a (fully) vaccinated child/adult who brings measles to the vulnerable. In fact, I cannot think of a similar situation where the index case had been vaccinated.

I agree that if your child looks like s/he could be contagious, you should call ahead and warn the office. It does not change the epidemiology of measles though and the fact that in this case, the decision of one family not to vaccinate their child is costing two other families a child. There are a number of ways in which this could have been prevented. 2xMMR is one.

You are specifically referencing measles but then are also painting a broad picture about all diseases, all parents who don't vaccinate. This MAY be the case for measles that it was not a vaccinated child who brought it in. But you are not just talking about measles. You blog is about al parents who do not vaccinate. You give ONE example of measles and SSPE. This is not right. You need to give a balanced account including how children who are vaccinated are silent reservoirs of disease, of how they can carry diseases asymptomatically and pass them on to under vaccinated or too young to be vaccinated. This is the information that most vaccinating parents do not know and because of these kinds of posts, feel self-righteous in pointing all fingers at unvaccinated, not realizing that their children are NOT 100% protected nor that their children are not disease free just because they are symptom free.

Anonymous, you are constructing a strawman, I wrote quite clearly that:

However, every parent who has a sick child has to think for a moment, before they haul it to the pediatricianThat reflects my opinion and what I tell parents: if your child could be contagious, call the practise, do not go straight in. However, the fact remains that parents of unvaccinated children have more and potentially more dangerous diseases to worry about and a much higher likelihood that it is something like measles than parents of a vaccinated child.

The question of "silent reservoirs" is a separate issue that we will address in the future, especially for pertussis. It does not really apply to measles in a quantitative manner.

As you mention self-rightiousness, I should add that I pity the parents of the unvaccinated index case. I am sure that they never once thought about the harm their decision could cause and they have to live with the guilt for the rest of their lives. However, this example should serve as a warning to every parent, but especially those whose children are most susceptible to measles, to think twice before taking their child with high fever into an ER or pediatrician's office. With the current accessibility of information via modern media, no parent can claim they were not aware of the potential deadliness of their actions.

no strawman .... not everyone can diagnose if a disease is contagious. Hell, it even took Mexico and the CDC some time to determine what this flu was and just how contagious it was. Not all VPD's initially present with clear symptoms which will indicate what disease it is. Your article needs to be re-written to specifically address measles in doctor's office. You are trying to target too many things at once. You are ignoring that even a partially vaccinated child could be responsible for the spread of serious diseases and could carry guilt as well for the spread of diseases.

not everyone can diagnose if a disease is contagious. ..snip.. Not all VPD's initially present with clear symptoms which will indicate what disease it is.My point precisely. You do not know what it is and at that point, *any* parent needs to think about the possibility of their child being contagious AND the unvaccinated child has a higher likelihood of having contracted a VPD than the vaccinated child. I think I said that already.

The above is an example of what can happen if parents 1. do not vaccinate and 2. do not think before they take their child into a waiting room. Therefore, nothing needs to be rewritten.

I would like to know why an unvaccinated infected kid would be more contagious than a vaccinated infected kid. And with 6 vaccinated kids getting infected, what does that say about the protection that vaccinations provide (or don't)?

I am new to this blog, but have found this entry to be very interesting. Correct me if I am wrong, but at least 3 of the six children that were infected were under 12 months of age. Therefore, they most likely had not received the measles vaccine. I can't see the movie, but would like to know the ages of the other 3 children. I'm interested to know the ages of the other three children. It is very likely that even over 12 months of age they may have not gotten their measles vaccine yet.

I would like to know why an unvaccinated infected kid would be more contagious than a vaccinated infected kid. And with 6 vaccinated kids getting infected, what does that say about the protection that vaccinations provide (or don't)?

As far as measles, it should be obvious why an infected unvaccinated child would be more contagious than vaccinated one. If a vaccinated child contracts measles, it is due to primary vaccine failure, which does happen in a very small percentage of children. There weren't 6 vaccinated children infected, they were all unvaccinated and some too young to be vaccinated. Herd immunity should have protected them, that is, if it was present.

That seems incredibly rare statistically that two of those six kids infected by the pre-teen would later develop SSPE. So sad.

I'm wondering why people bring their kids to the doctor so easily anyway. Unless the kids look really ill, develop worrysome symptoms, and/or you can't keep any food or liquid down them, why not just stay home and let the illness run its course.

I think this issue is about acting responsibly when you have a sick child. Yes, if measles is circulating, unvaccinated children are more likely to become infected and infectious.

What are the risk factors for SSPE? Is a child who is 7 years old at the same risk as a child who is 7 months old? What can parents do to protect their babies who are too young to be vaccinated? (other than place their trust in herd immunity)

How, in your opinion, can a parent responsibly choose not to vaccinate for measles?

Risk factors for SSPE, are measles infection, not vaccination and age at infection, the younger, the higher the risk. Oddly, living in a rural environment appears to be a risk factor for SSPE: http://aje.oxfordjournals.org/content/111/4/415.short

If parents live in a community that has a high vaccine exemption rate (this is available through your state public health department), then they may wish to avoid exposing their children until they are old enough to be vaccinated (easier said than done), especially during an outbreak of measles.

In my opinion, there is no responsible choice to forego measles vaccine, excepting medical contraindication.

I have it on good authority that people who get both doses of the MMR are virtually impenetrable by me. That is, over 99% of people with both doses will be completely immune. That is more than enough to kill me.

So, please, don't vaccinate if you DO want me to keep doing those things to non-immune children... Those who are too young to be vaccinated, whose immune system is too weak to fight me off, and those whose parents have been scared away from immunizations by lies and frauds like Andy Wakefield's. Thank you.

My question is relevant to parents who have not been convinced of the safety of the MMR, but who still feel a social responsibility in the event of their child being sick and running a fever with a runny nose.

Some parents are going to choose not to vaccinate with the MMR regardless of opinions of online personas or their doctors. What message would you want them to get, knowing that you have no power to convince them to vaccinate with the MMR.

Is someone seriously commenting as the measles virus? Honestly... Yes, the childrens' little immune systems are too weak to fight off the measles. They're also not strong enough to change the effects that the MMR vaccine has on them. I love how everyone assumes that non-vaccinating parents are uneducated or conspiracy theorists. Even the CDC website says that the MMR vaccine can cause "deafness, permanent seizures, or permanent brain damage" even if in "rare cases". I'd rather not play Russian Roulette with my child's health. Maybe it would happen...maybe it wouldn't. Just like my child may get the measles...or she may not. At least by not vaccinating I'm only taking one risk. If I vaccinated my child I'd be taking the risk of her 1)having an adverse reaction to the vaccine and 2)possibly getting the disease anyway.

As for the comment on the 13th, I'm not sure if this is what you were asking, but I found a doctor that is very accepting of non-vaccinating patients. If my child became ill, I would call the office ahead of time, inform them of my child's symptoms and the fact that she is not vaccinated and see how they would like to proceed.

My opinion is that all parents do what they think is best for their child. I'm not pro or anti vaccine. This is just what works for me and my child. Anyone else is free to do what they would like with their child (as it should be).

Anyone else is free to do what they would like with their child (as it should be).

Actually, you don't seem to have gotten the point of this story. The whole point is that Micha's and Natalie's parents were NOT free to do "what they like". Instead, the parents of the unvaccinated pre-teen forced disease on their babies (and a handful other kids in the waiting room) and condemned them to death.

You are assuming that the risks of Maybe it would happen...maybe it wouldn't. are equal (as in 50/50), but they are not. Severe consequences from MMR are several orders of magnitude less likely than severe consequences from measles and the only reason the risk of contracting measles is low, is that other people vaccinate. You are free riding herd immunity, while turning your kids into potential murder weapons.

Anonymous, you horrible creature. My daughter was exposed to measles at 8 months in an ER because some idiot parents refused to have their child vaccinated. I had her vaccinated then and there. Thank God, she didn't come down with measles. Instead all we had to worry about was the risk of injury from vaccinating too soon. Isn't that a lovely present to give another family?

What if your kid was one of the X % to have an adverse reaction to to the vaccine - you wouldn't be taking the same way then. You can't go around bashing people this way, you have to be respectful of every parents decision. It's hard enough that we have to make these decisions for another tiny human being as it is. If we vaccinate, what if they have an adverse reaction, worse case scenario death - and if we don't vaccinate and they catch something....

What if your kid was one of the X % to have an adverse reaction to to the vaccine - you wouldn't be taking the same way then.

And you know this how? We're not talking about faux vaccine reactions that parents convince their children had, we are talking about real vaccine reactions and for your information, I've talked to several parents whose children did have real vaccine reactions and they are still supportive of vaccines.

You can't go around bashing people this way, you have to be respectful of every parents decision.

No, we don't have to be respectful of your bad decisions. I'm not respectful of parents who don't put their children in proper car seats and allow their children to behave like little prats so why should I be respectful of your over-inflated sense of entitlement?

It's hard enough that we have to make these decisions for another tiny human being as it is. If we vaccinate, what if they have an adverse reaction, worse case scenario death - and if we don't vaccinate and they catch something....

And this is why you don't have any respect - you've created a false equivalency by putting vaccine reactions on the same par as disease complications. If you actually did do the research with proper studies then it is obvious that serious vaccine reactions are orders of magnitude less common than disease complications.

I don't know if you have heard this already, but Natalie just died. Here is a German news article: http://www.lz.de/home/nachrichten_aus_lippe/bad_salzuflen/bad_salzuflen/5171731_13-jaehrige_Natalie_starb_an_Folgen_von_Masern.html

Translated: So it is confirmed that the "case 0" eleven year old was not vaccinated? That he had such close contact to seven other children that they got the disease _from_him_ and not from, for example, recently vaccinated children who were shedding virus in the same timeframe? -- Finally, why does this one isolated case count as scientific evidence of anything, while tens of thousand of reported vaccine injury and death do not count for anything?

#1 - the child was indeed unvaccinated for measles - as was confirmed by the German Ministry of Health.

#2 - the MMR does not "shed" in a way that would cause infection, the worse that can happen is you might get exposed to the vaccine antigen, which would merely boost your immune system because it isn't a "whole" virus and capable of replication.

#3 - any death is a tragedy. And no, "reports" don't count for anything unless they can be backed up with actually evidence.

Anonymous arguing against Catherina (April 2009), you obviously haven't been exposed to measles yourself, nor have your children (if you have any). Your reaction is very ignorant, very biased, and typically like what those anti-vax, pro disease people behave.

Why don't you expose yourself and your family to measles, rubella, whooping cough etc. and see what happens and what FUN you'd be having.

My 9 month old is too young to be vaccinated, and everyday I worry about him catching these diseases caused mostly by irresponsible, ignorant parents not vaccinating their children without a good reason, such as medical illness. I lose my respect for all of you who don't vaccinate based on irrational, whimsical reasons. What a disgrace to society.

When disease hits YOU and YOUR FAMILY. I won't feel sorry, no. Good luck.

Is there any substantiation of this story in English, even a newspaper article, something translated into English? Preferably from a source more likely to be objective than an internet blog. Medical records, perhaps? Videos in German are worthless as corroboration of facts for people who do not speak German. Without corroboration, this story is merely anecdotal. How do you prove that a disease someone gets ten years after having measles in infancy is caused by having had measles in infancy? Did the measles virus stay latent in the children's bodies for ten years? When most children got measles disease naturally, most babies were immune from measles due to natural antibodies from their mothers' breastmilk and placenta. However, vaccination does not provide the same level of antibodies in mothers, and now we have the babies of vaccinated mothers--too young to vaccinate---being at risk for measles, due to their mothers' vaccinations. This interference with natural immunity is an unfortunate side effect of mass vaccination and, it would seem, an underlying cause of the babies' getting measles to begin with.

Is there any substantiation of this story in English, even a newspaper article, something translated into English? Preferably from a source more likely to be objective than an internet blog. Medical records, perhaps? Videos in German are worthless as corroboration of facts for people who do not speak German. Without corroboration, this story is merely anecdotal. How do you prove that a disease someone gets ten years after having measles in infancy is caused by having had measles in infancy? Did the measles virus stay latent in the children's bodies for ten years?

So you don't know jack about SSPE yet hear you are whinging about "anecdotes" and "corroboration". SSPE is specifically mentioned but you couldn't even take the time to find out what that is or ask? Just so you know, yes SSPE is a 100% fatal disease that results in a previous wild-type measles infection and we have these really nifty high-tech procedures that can figure these things out. Crazy I know; it's like magic or something.

When most children got measles disease naturally, most babies were immune from measles due to natural antibodies from their mothers' breastmilk and placenta. However, vaccination does not provide the same level of antibodies in mothers, and now we have the babies of vaccinated mothers--too young to vaccinate---being at risk for measles, due to their mothers' vaccinations. This interference with natural immunity is an unfortunate side effect of mass vaccination and, it would seem, an underlying cause of the babies' getting measles to begin with.

You don't even know what SSPE is but wax stupidly on about maternal antibodies. I seemed to have missed what science credentials you have. You also forgot to include any evidence for your extraordinary claims. Fact is, maternal antibodies for wild-type measles isn't that long-lived. Pretty much gone by nine months and not even fully protective at six months. Fact is, infants in countries with high MMR uptake very rarely acquire measles unless they're unfortunate enough to be sitting next to some dumb anti-vaxxer's infected special snowflake. Compare that to the pre-vaccine era when infants were routinely infected. Why do you want that back?

"s there any substantiation of this story in English, even a newspaper article, something translated into English? Preferably from a source more likely to be objective than an internet blog. Medical records, perhaps? Videos in German are worthless as corroboration of facts for people who do not speak German. Without corroboration, this story is merely anecdotal...."

Yes, there is substantiation of SSPE cases in Germany, available in the English language. Here...

They don't last as long, hence needing to get more vaccinations, when the natural immune child has the antibodies forever. And herd immunity is just an excuse to scare parents into immunizing. You can't say immunized children don't get sick even after the immunization, sometimes they even get sick because of it. So saying that if everyone is immunized means the disease is eradicated is a little silly.

there is no indication that vaccine-induced immunity against measles wanes. There is primary vaccine failure, which is why we vaccinate twice. Smallpox has been eradicated by vaccination (and targeted quarantine), with polio we are almost there. It is the misinformed eco-nostalgia that is keeping measles alive. There is no reservoir for measles apart from humans and great apes (zoo apes are all vaccinated), so 2xMMR can eradicate measles.

The antibodies stay in the infant as long as you keep breastfeeding. The way breastfeeding works is practically the baby giving you what they have so you can give them the antibodies if you haven't already.

there is no transmission of measles specific antibody past 2 weeks post partum. Maternal immunity relies on transplacental immunity, which is passive, obviously not renewed after birth and decays with a half life of 3 to 4 weeks. This leaves babies unprotected by 6 months of age (which is also was was observed in pre-vaccine times, most infant measles death were in the second half of infancy). Notably, SSPE will also occur in babies without overt clinical measles due to maternal antibodies.

If children receive the first dose of the 2-dose series between ages 12-15 months of age and the second dose of the 2-dose series, approximately 98-99 % of vaccinated individuals will be immune and that immunity is lifelong.

Where did you hear that measles "is eradicated"?

Do you misunderstand the statements that the United States was declared free of endemic measles by the WHO fourteen years ago?

"The antibodies stay in the infant as long as you keep breastfeeding. The way breastfeeding works is practically the baby giving you what they have so you can give them the antibodies if you haven't already."

You are mistaken. The passive immunity a baby acquires through breast feeding is mainly associated with the colostrum and that immunity fades around one year of age. That's the reason why the recommendations for all babies (who have placental passive immunity only) and breast fed babies is to be vaccinated with MMR vaccine on or just past their first birthdays, so that the fading passive maternal immunity does not interfere with the immunity conferred by the MMR vaccine.

CDC report: “As of July 1982, 634 individuals suspected of having SSPE, with onset from 1956-1981, had been reported to the registry; of these, 368 were U.S. citizens who met the case definition of SSPE and had onset of symptoms between 1969 and 1981 (Figure 1). Fifty-five percent (202) of the 368 confirmed cases had a history of only measles infection; 14% (51) had a history of only measles vaccination; and 17% (63) had a history of both, with the natural illness most frequently preceeding the vaccination. The remaining 14% (52) gave no positive history of having natural measles infection or measles vaccination.” http://www.cdc.gov/mmwr/preview/mmwrhtml/00001185.htm

1994 IOM review: “SSPE is a recognized sequela of measles infection, and it is biologically plausible that it could occur after administration of the live attenuated viral vaccine. Identification of the cause of SSPE as wild-type or vaccine-strain measles virus has not been possible. The viruses isolated from patients with SSPE differ from the known measles viruses. The viruses may have become altered by the prolonged residence in the brains of the patients, or they may have been different at the time of the original infection.” http://www.nap.edu/openbook.php?record_id=2138&page=136